CODING Q&A

The Top Retinal Surgical Coding Errors in 2008

ANSWERS PROVIDED BY RIVA LEE ASBELL

Having recently completed several audits of large retina practices, I have noted some common patterns of miscoding. In addition, the listservs have been replete with surgical coding queries accompanied by good and bad answers. Here are several of the most common coding errors and their "fixes," which should set you on the right path for 2009.

CODE SELECTION PROBLEMS

66850 vs 66852: When a lensectomy is performed in conjunction with a vitrectomy, the appropriate code, according to the instruction in the CPT manual, is 66850 (removal of lens material; phacofragmentation technique [mechanical or ultrasonic] [eg, phacoemulsification], with aspiration). Many retina surgeons and billing personnel would disagree because an anterior approach is understood to be used in this code. They would choose CPT code 66852 (removal of lens material; pars plana approach, with or without vitrectomy) because of the pars plana approach in the description. Please do not do this. I have received many inquiries about denials when practices have used CPT code 66852. For Medicare claims, you never will be paid because under the National Correct Coding Initiative (NCCI), the code is bundled with all vitrectomy and retinal detachment repair codes.

Riva Lee Asbell can be contacted at www.rivaleeasbell.com where the order form for her new book "Tips on Ophthalmic Surgical Coding by Subspecialty" can be found and downloaded under Products/Books.

67108 vs 67112: Determining which of these two codes to use is always problematic. A little background may help clear up some confusion. CPT code 67112 (repair of retinal detachment by scleral buckling or vitrectomy on patient having previous ipsilateral retinal detachment repair[s]) was developed for use with insurers who refused to pay CPT code 67108 (repair of retinal detachment; with vitrectomy) more than once or twice, such as for recurrent retinal detachment. Reimbursement for 67112 is lower than that for 67108, so to optimize reimbursement when appropriate, use 67108 with a 78 modifier. Be aware, however, that you cannot use 67108-78 for the second procedure unless a vitrectomy is performed. Modifier 78 is described as:

"Unplanned return to the operating/procedure room for a related procedure by the same physician following initial procedure for a related procedure during the postoperative period."

Remember that both of these codes usually takes modifier 78 when used in the global period. If the procedure is planned prospectively, goes from lesser to greater or diagnostic to therapeutic, then modifier 58 would be indicated instead. Modifier 78 pays at 70% of the allowable for major procedures for Medicare, whereas modifier 58 pays at 100%.

67036 vs 67121: Which code would you use for removal of silicone oil: 67036 (pars plana vitrectomy) or 67121 (removal of implanted material, posterior segment; intraocular)? In fact, 67121 is the better choice because, in most instances, removal of the vitreous was completed in the original procedure.

You should use modifier 58 for coding the second procedure since the original assumption was that the silicone oil would be removed, even if that does not ultimately happen.

67108 vs 67113: CPT code 67108 is described as: Repair of retinal detachment with vitrectomy, any method, with or without air or gas tamponade, focal endolaser photocoagulation, cryotherapy, drainage of subretinal fluid, scleral buckling, and/or removal of lens by same technique.

What is the difference? When do you use "complex"? What can be billed additionally? My audits have shown that many practices are either not using "complex" when they should or they are overusing it.

The key word in the description of CPT code 67113 is "complex" not "complication." This parallels the usage for complex cataract extraction. It is not meant to be used when the surgeon encounters complications during surgery. Rather, an element of prospective planning and knowledge is usually present.

Both codes include just about every technique. The principal difference between the two codes is that 67113 includes epiretinal membrane peeling. This code essentially replaces the old 67038 + 67108 standby combination, which was eliminated effective January 2008.

QUESTIONS FROM THE TRENCHES

Q. One of our surgeons performed pars plana vitrectomy for a retained piece of lens material, which was billed as 67036 (pars plana vitrectomy) at $1650 and 67121 (removal of retained lens material) @ $1250. Medicare paid $625 on 67121 and disallowed 67036 as a bundled procedure. How should this have been billed? Should we have used a modifier to unbundle these? The clinic has billed only 67036, and they have a "no charge" on the 67121 because they feel it is a bundled procedure related to cataract surgery by a different doc a few weeks earlier. Help!

A. CPT code 67121 is for removal of implanted material in the posterior segment, as described earlier in this article (for silicone oil removal). It was originally developed for retrieval of intraocular lens material from the posterior segment.

In this case, the wrong code was used for retrieval of the crystalline lens material. The correct codes were 67036 + 66850. Look how much money was lost by both the ASC and the clinic.

Q. We have a patient with a retinal detachment, who is scheduled for pars plana vitrectomy. If the surgeon performs the vitrectomy and does indirect laser instead of endolaser, what code should we use to bill this? Can we use 67040 even though indirect laser was used instead of endolaser? I have the same question if cryotherapy is used instead of endolaser.

A. The NCCI is a very important instrument used by Medicare and most other payers. Visit www.cms.hhs.gov/nationalcorrectcodinited/01_overview.asp? for an overview.

Never unbundle code edit pairs on a whim. All the indirect lasers are bundled with the vitrectomy and retinal detachment repair codes. You cannot code indirect laser procedures using endolaser codes. This is fraud. There is intent. When you use CPT codes 67108 or 67113, indirect and laser photocoagulation as well as cryotherapy are bundled.

Q. Our patient had pars plana vitrectomy, air-fluid exchange, injection of silicone oil for total retinal detachment. Within the global period, the patient had cryotherapy and scleral buckling for recurrent detachment. The doctor coded 67112: Repair of retinal detachment by scleral buckling or vitrectomy on patient having previous ipsilateral retinal detachment repair(s) using scleral buckling or vitrectomy techniques.

Can we bill 67107 instead? I don't completely understand why there is a code like 67112. In this case, a vitrectomy (plus) was done at the initial surgery, and a scleral buckling (plus) was done at the second surgery. Reimbursement is better for 67107 and, to me, makes more sense.

A. The previous question was posted online. The answers posted in response were fraught with misinformation and misconceptions. Below, I've included 2 of the responses, in italics, followed by my comments:

• 67112 is the correct code if there's a need for reoperation for an RD within the global period. The thinking in setting up that code was that there would be some payment for the extra services (as opposed to no payment for a retreatment within a global period by definition), but that those re-op procedures would reimburse less than first-time cases.

RLA comments: The correct code choice depends on the operation. For Medicare, CPT code 67108 is the better choice financially. For whichever code you use, you must append modifier 78. In order to use 67108, however, a pars plana vitrectomy must be performed. The query does not mention pars plana vitrectomy being performed.

• My understanding is that 67112 is used when the eye has had a previous operation for RD by a different surgeon, and this is the first procedure that you have done. In the present case, I'd code 67107-78, using modifier 78 to indicate an unplanned return to the OR for a procedure related to the first operation.

RLA comments: The correct CPT code is 67112-78. According to CMS regulations, when using modifier 78 in the global period, it applies to the same surgeon. RP